is shooting for employee participation versus engagement
lowering the wellness bar?

March 14, 2012

in wellness

bob merberg has been providing thoughtful commentary on shapeup’s recently released survey data in an excellent series on his blog. his most recent post in the series, engagement vs. participation: shaping up or just showing up? ponders whether it’s enough for employers to merely strive for participation:

“When I first started hearing about health engagement, the  very purpose of the phrase was
to set engagement apart from participation. Engagement referred to having a genuine and emotionally influenced connection to health and, in many cases, health behavior change. Participation meant merely taking some sort of action—regardless of sincerity or value (completing a program, getting a biometric screening, and so forth).

Some employees participate in programs exclusively to obtain an incentive. Are they engaged?”

i agree with bob about there being a difference between participation and engagement. that difference, as i see it, is the degree to which someone is actually invested in his or her health. by that i mean actively educating him or herself about it and taking pains to improve and manage it versus checking a box to get something done—merely participating—without care or mindfulness for what health benefits it may deliver.

bob continues his argument about whether it’s enough for employers to concentrate on and calculate participation as if it matters until he reaches this final point:

“In our environment of incentive-laced wellness programs, embodied by the proliferation of so-called outcomes-based programs, the distinction between participation and true engagement becomes even more significant. When an employee enrolls in a program (or, I’ll argue, even achieves a biometric improvement) exclusively to reduce their insurance premium or access a better medical plan, it may not be because they are engaged. Heck, it’s barely participation. I’d use a completely different word to describe it: compliance.

“And I’m not sure compliance is wellness, at all.”

here’s where i veer from bob’s line of thought. if behavior change were easy and people did what they (and we) knew was best for their health, compliance wouldn’t be enough. but in our real world, neither of those is true, and so compliance becomes a matter of grave importance.

here’s an example. yesterday a friend updated me about her brother-in-law’s health condition. at 42 years old, he had a serious heart attack. his mother flew to his side to help him with recovery and to manage his business, and she’s been aghast as she’s watched him resume smoking, continue his excessive drinking, and in all other ways be noncompliant with his recommended recovery. while my friend was shocked at his behavior, i informed her that going back to old habits, even after a heart attack, was quite normal, unfortunately.

in this case, were my friend’s brother-in-law to be compliant, he’d be back on the road to wellness. in fact, he’d be on a better road than he was before the heart attack.

i see this, too, with employees and their stories of complying with biometric screenings, or complying with preventive checkups, or complying with tobacco-free workplace policies. or really, even nudging people through behavioral cues and the built environment. there’s no intrinsic motivation involved. it’s pure requiring, guiding or steering.

we may not have their hearts and minds when we start with compliance and participation, but we do start influencing what they do with their bodies. with that, the hope is their hearts and minds may follow.

f

note: this post doesn’t extend to outcome-based wellness efforts, for which i have reservations.

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{ 4 comments… read them below or add one }

Leah O'Neill March 14, 2012 at 9:36 am

Great article, Fran. And it points to the need for “required participation” to get people started towards wellness, even if they don’t really want to. My feeling is that programs that offer incentives or required participation are valuable in getting people to take that first step, and to hopefully start seeing results. I also think programs should include elements of engagement, by surveying and understanding what motivate individuals to make behaviour change, to create long term change. With health marketing, I feel it’s so important to understand why people engage in certain behaviours (either positive or negative) and why people don’t do certain behaviours (either positive or negative) and then use those motivations to create long term healthy behaviour change.

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fran March 15, 2012 at 12:41 pm

leah, i agree on the value of incentives for helping to launch people. here’s a great Q&A with paul hebert on that and more: http://www.freerangecomm.com/2011/06/incentives-for-health-engagement-and-behavior-change/

f

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Bob Merberg March 14, 2012 at 10:37 am

I appreciate the thought you’ve given to this matter, Fran, and to my blog post.

I hold a deep-seated belief in individuals’ ability to transform their health and, consequently, to transform their lives, and to transform the lives of those around them. I believe that this is what wellness is. It is directly related to being able to transform your whole health — assisted by supportive environments and behavioral strategies. Wellness empowers. It honors the human spirit and its impulse to thrive.

When we manipulate individuals to take action for their own health (via financial consequences, for example), we convey a lack of faith in their ability to cultivate intrinsic motivation and, therefore, their ability to transform. This is why I differentiate between compliance and wellness and why I say that the compliance driven outcomes-based wellness programs do not promote true wellness. Wellness leaders like to say that pressuring people into taking action will trigger their intrinsic motivation, but there is little evidence of this. In fact, there is some evidence that extrinsic motivators reduce people’s intrinsic motivation.

(On a population level, I do agree there are times when encouraging compliance leads to a positive result for the public health. Smoking bans, as you alluded, are a good example. But when I use the word wellness, I am referring to something that includes, but goes well beyond, physical health.)

Wellness leaders who believe that their participants need to be strong-armed into behavioral change generally, in my opinion, perpetuate an outdated, prescriptive model of health.

Regarding the example of your friends’ brother-in-law: I’m sorry to hear about his situation. Of course, I want him, and everyone, to maintain positive behavioral change and to stick to any programs he has available to him. Typically, these days, this would be considered more a matter of “adherence” rather than “compliance.” (Medical and behavioral literature includes several compelling discussions on the distinctions between compliance, adherence, and concordance. There is not universal agreement, but most leading health organizations, such as WHO and the NIH, would characterize the scenario you present as a matter of “adherence.”) But even if one prefers to call it compliance, I maintain that complying or adhering to a health management plan in order to improve your health is different from participating in a program because you want to keep your job or pay a lower premium. The former can be transformative or is a sign that transformation has taken place. The latter is disempowering and probably fleeting.

The best example of how compliance differs from wellness participation: An employer who has an employee participate in a biometric screening will count that employee as participating in wellness. If that’s the case, life insurance companies have had nearly 100% participation in “wellness programs” for as long as I can remember. Life insurance plans have always had customers submit to biometric screenings. No one ever considered it a wellness program. It’s compliance. Now, when an employer has you submit to the very same medical procedure, why are we considering it participating in wellness?

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fran March 15, 2012 at 1:03 pm

bob, there’s so much in here to respond to. let me take a crack at a few, with more questions than answers!

manipulation. manipulation is typically done with a level of deceit. if the terms are openly communicated, is it manipulation? how do we define what is and isn’t manipulation? isn’t it manipulating to put traffic light symbols on salad bar tongs?

intrinsic versus extrinsic. i, like leah, believe that you sometimes must start with the latter to get to the former. read the interview with paul hebert that i posted w/my reply to her comment for his two cents on the subject.

not sure what category! edelman has a model of health profiles that groups people according to t heir level of health engagement. they range from “apathetics” to “actionists.” they, as i would also do, encourage employing your actionists to rope in your apathetics. is this manipulation? if someone gets roped in to do something with a friend that they might not otherwise do, is that strong-armed and to be encouraged? or is this what we’re saying is the beauty of social networks?

outcomes-based wellness. i mentioned at the end of the post that my views on “participation” and “engagement” veer when it comes to outcomes-based wellness. you know that i feel wellness is personal and that employers, in their need to find a solution, are seeking ever stricter sticks, like outcomes-based wellness. an exchange i had with a whole foods cashier about their outcomes-based approach is a good example of why i struggle with this approach to wellness. this cashier was ecstatic. their tiered-discount based on biometrics worked great for her. she ate all kinds of junk, but her BMI and other metrics were solid by whole foods’ standards. she’s not necessarily healthy, but she looks good on paper, in other words. with the way outcomes-based wellness is designed, you get good on paper. you may also get frustrated employees who are doing everything right but genetically, their numbers are high. or disappointed employees, those who are trying to make changes but are falling down. they get dinged with outcomes-based wellness and may just give up. i don’t see how any of these scenarios translate into good health for the individual or the employer.

f

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